What is the appropriate management for a patient with a hacking cough, potentially indicating underlying respiratory conditions such as bronchitis, pneumonia, or Chronic Obstructive Pulmonary Disease (COPD)?

Management of a Patient with a Hacking Cough

Immediate Assessment

First, determine if this is acute (≤3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) cough, as this fundamentally changes your diagnostic and treatment approach 1, 2.

For acute cough presentations, immediately assess for:

• Respiratory distress, tachypnea, tachycardia, dyspnea, or abnormal vital signs—these require urgent chest X-ray to rule out pneumonia 1, 3
• Fever >4 days, new focal chest signs, or asymmetric lung sounds suggest pneumonia rather than simple bronchitis 1, 3
• In patients >75 years with fever, or those with cardiac failure, insulin-dependent diabetes, or serious neurological disorders, strongly consider pneumonia and initiate antibiotics 1

Acute Cough (<3 weeks)

For acute bronchitis without pneumonia, do NOT prescribe antibiotics—they provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, and C. difficile infection 1, 4.

Diagnostic Criteria

• Acute bronchitis should only be diagnosed when pneumonia is ruled out clinically or radiographically, AND the common cold, acute asthma, and COPD exacerbation have been excluded 1
• If the patient has had ≥2 similar episodes in the past 5 years, consider undiagnosed asthma (present in 65% of such cases) 1

Treatment Approach

For symptomatic relief in acute viral bronchitis:

• Prescribe dextromethorphan or codeine for bothersome dry cough 1
• First-generation antihistamine/decongestant combination for upper airway symptoms 2, 3
• Naproxen for associated discomfort 3
• Honey for cough suppression (if not contraindicated) 3
• Adequate hydration 3
• Do NOT prescribe expectorants, mucolytics, antihistamines alone, or bronchodilators—these are ineffective 1

Safety Net Instructions

• Advise patients the cough typically lasts 2-3 weeks 4
• Return if symptoms persist >3 weeks, as other diagnoses must be considered 1
• Return immediately if fever exceeds 4 days or dyspnea worsens 1

Subacute Cough (3-8 weeks)

Obtain a chest radiograph if pneumonia is suspected based on tachypnea, abnormal lung findings, or hypoxemia 2.

Key Historical Elements

• Review ACE inhibitor use—these cause cough in susceptible patients, with resolution taking 26 days to 40 weeks after discontinuation 1, 2
• Assess smoking status and counsel on cessation 2
• Determine if post-infectious (following recent respiratory infection) 2

Diagnostic Testing

If asthma is suspected:

• Perform spirometry; if non-diagnostic, proceed to bronchoprovocation challenge 2
• If testing unavailable, trial inhaled bronchodilators plus inhaled corticosteroids 2

For suspected non-asthmatic eosinophilic bronchitis:

• Induced sputum testing for eosinophils if available 2
• Otherwise, empiric trial of inhaled corticosteroids 2

For upper airway cough syndrome:

• Treat with first-generation antihistamine/decongestant combination 2

Chronic Cough (>8 weeks)

A systematic approach to diagnosis and treatment is the most effective management strategy 1.

Initial Workup

• Chest X-ray is essential 5, 6
• Pulmonary function testing to identify obstructive (asthma, COPD, bronchiectasis) or restrictive patterns 5, 6
• Consider chest CT only if chest X-ray is abnormal, clinical suspicion of underlying disease exists, or initial workup is negative with persistent symptoms 1

Common Etiologies to Systematically Evaluate

Upper airway cough syndrome (postnasal drip):

• One of the most common causes, often with normal physical exam and sinus X-rays 5
• Treat with first-generation antihistamine/decongestant 1

Asthma/cough-variant asthma:

• Consider if cough worsens at night or with cold/exercise exposure 1
• Bronchoprovocation testing if baseline spirometry normal 5
• Treat with inhaled bronchodilators and corticosteroids 1

Gastroesophageal reflux disease:

• Common cause of chronic dry cough 1, 7
• May require empiric trial of acid suppression 1

COPD:

• Usually accompanied by phlegm production and breathlessness 1
• Smokers with persistent cough are at risk for developing COPD 1

Bronchiectasis:

• Can present as "dry" bronchiectasis with persistent cough 1
• Prevalence in specialist cough clinics is 4% 1

ACE inhibitor-induced cough:

• Cough resolves after drug cessation (median 26 days, up to 40 weeks) 1
• Most patients tolerate angiotensin II receptor blockers as alternatives 1

Pertussis:

• Suspect if cough >2 weeks with paroxysmal features, whooping, or post-tussive emesis 1, 4
• 10% of chronic cough patients have positive Bordetella testing 1

Red Flags Requiring Advanced Imaging

Obtain chest CT if any of the following are present:

• Hemoptysis 6
• Weight loss 6
• Night sweats 3
• History of cancer, tuberculosis, or AIDS 3
• Recurrent pneumonia 6
• Persistent symptoms despite optimal treatment 6

Treatment of Underlying Respiratory Diseases

COPD exacerbations:

• Antibiotics indicated if all three present: increased dyspnea, increased sputum volume, increased sputum purulence 1
• Also consider antibiotics in severe COPD exacerbations 1
• First-choice: tetracycline or amoxicillin; alternatives: azithromycin, clarithromycin, roxithromycin 1

Pneumonia:

• Cough suppression is contraindicated as clearance is important 1

Bronchiectasis:

• Cough suppression relatively contraindicated 1

Lung cancer:

• Cough is the fourth most common presenting feature 1
• Radiotherapy and opioid/non-opioid antitussives recommended 1

Idiopathic Chronic Cough

If comprehensive evaluation is negative:

• Predominantly affects middle-aged women, often starting around menopause 1
• Associated with heightened cough reflex and lymphocytic airway inflammation 1
• Treatment options include dextromethorphan, baclofen, nebulized lidocaine/mepivicaine, or low-dose morphine 1
• Consider cough hypersensitivity syndrome and trial gabapentin or pregabalin with speech therapy 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics for acute bronchitis without evidence of pneumonia or bacterial infection 1, 4
• Do not rely solely on cough characteristics for diagnosis—use systematic evaluation 2
• Do not perform chest CT routinely in chronic cough; reserve for abnormal chest X-ray or high clinical suspicion 1
• Do not suppress cough when clearance is important (pneumonia, bronchiectasis) 1
• Do not prescribe combination cough preparations 8
• Do not overlook ACE inhibitors as a reversible cause 1, 2